Semi-circular ablation catheter

ABSTRACT

A medical device is disclosed, including a handle assembly; an elongate body coupled to the handle assembly, the elongate body defining a guide wire lumen therethrough; and a substantially semi-circular electrode array coupled to the elongate body. The device may include a substantially rigid shaft extending distally from the elongate body and defining a lumen therethrough, the shaft including a substantially rigid segment, and a flexible coil coaxial with and extending distally from the shaft.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a Continuation of U.S. Pat. No. 10,765,476, filed May 31, 2018 and is a Divisional of and claims priority to U.S. Ser. No. 13/281,761, titled SEMI-CIRCULAR PULMONARY VEIN ABLATION CATHETER, filed Oct. 26, 2011, now an issued U.S. Pat. No. 10,064,678, issued Sep. 4, 2018 the entirety of which is incorporated herein by reference.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

n/a

FIELD OF THE INVENTION

The present invention relates to medical systems and methods of use thereof having a selectively configurable treatment array.

BACKGROUND OF THE INVENTION

Numerous procedures involving catheters and other minimally invasive devices may be performed to provide a wide variety of treatments, such as ablation, angioplasty, dilation or the like. For example, to treat cardiac arrhythmias, physicians often employ specialized ablation catheters to gain access into interior regions of the body. Such catheters include tip electrodes or other ablating elements used to create ablation lesions that physiologically alter the ablated tissue without removal thereof, and thereby disrupt and/or block electrical pathways through the targeted tissue. In the treatment of cardiac arrhythmias, a specific area of cardiac tissue having aberrant electrically conductive pathways, such as atrial rotors, emitting or conducting erratic electrical impulses, is initially localized. A user (e.g., a physician) directs a catheter through a vein or artery into the interior region of the heart that is to be treated. Subsequently, the ablating portion of the selected device is next placed near the targeted cardiac tissue that is to be ablated, such as a pulmonary vein ostium or atrial wall.

An ablation procedure may involve creating a series of inter-connecting lesions in order to electrically isolate tissue believed to be the source of an arrhythmia. During the course of such a procedure, a physician may employ several different catheters having variations in the geometry and/or dimensions of the ablative element in order to produce the desired ablation pattern. Multiple devices having varying dimensions and/or shapes may also be employed to account for variations in anatomical dimensions from patient to patient. Each catheter may have a unique geometry for creating a specific lesion pattern or size, with the multiple catheters being sequentially removed and replaced to create the desired multiple lesions. Exchanging these various catheters during a procedure can cause inaccuracies or movement in the placement and location of the distal tip with respect to the tissue to be ablated, and may further add to the time required to perform the desired treatment. These potential inaccuracies and extended duration of the particular procedure increase the risk to the patient undergoing treatment.

In addition, while some existing devices provide may provide for some adjustability in their geometry, the effective ability to make such adjustments may be hampered by kinking or other unwanted impediment that frustrates the ability of one or more controls on a proximal portion of a device operated by a physician to accurately translate into the desired modification at a distal portion of a device within the patient.

In light of the above, it is desirable to provide a medical device having multiple, effectively-controllable shapes or dimensions, thereby reducing or eliminating the need for additional medical devices having varied, but limited geometric orientations, and thus, limited ability to provide multiple ablative patterns or sizes.

SUMMARY OF THE INVENTION

The present invention advantageously provides a medical system and methods of use thereof providing multiple, effectively-controllable shapes or dimensions. For example, a medical device is disclosed, including a handle assembly; an elongate body coupled to the handle assembly, the elongate body defining a guide wire lumen therethrough; and a substantially semi-circular electrode array coupled to the elongate body. The electrode array may be transitionable into a substantially linear configuration and/or may include a plurality of electrodes disposed on a carrier arm, the electrodes being disposed on approximately 50% of the length of the carrier arm. At least a portion of the carrier arm may be coaxial with the guide wire lumen, and/or the carrier arm may define an opening for passage of a guide wire. The carrier arm may define a rounded distal tip. The medical device may include a substantially rigid shaft extending distally from the elongate body and defining a lumen therethrough, the shaft including a substantially rigid segment, and a flexible coil coaxial with and extending distally from the shaft. A distal end of the carrier arm may be movably coupled to the shaft. The device may include a linear actuator coupled to the carrier arm for the linear manipulation thereof and/or a rotational actuator coupled to the carrier arm for the rotational manipulation thereof. The device may include a radiofrequency signal generator in electrical communication with the electrode array.

A medical system is also disclosed, the system including a catheter body defining a proximal portion and a distal portion; a substantially rigid shaft extending from the distal portion of the catheter body; a flexible coil extending from the shaft; a carrier arm fixedly coupled to the catheter body and movably coupled to the shaft; and an electrode array disposed on the carrier arm. The electrode array may be transitionable from a substantially linear configuration to a substantially semi-circular configuration. The system may include a distal stop coupled to the shaft that limits a range of movement of the carrier arm and/or the catheter body may include a guide wire lumen coaxial with the shaft. The system may include an electrocardiograph unit in electrical communication with the electrode array; and a radiofrequency signal generator in electrical communication with the electrode array. The system may include a linear actuator coupled to the shaft for the linear manipulation thereof and/or a handle assembly coupled to the proximal portion of the catheter body.

BRIEF DESCRIPTION OF THE DRAWINGS

A more complete understanding of the present invention, and the attendant advantages and features thereof, will be more readily understood by reference to the following detailed description when considered in conjunction with the accompanying drawings wherein:

FIG. 1 is an illustration of an example of a medical system constructed in accordance with the principles of the present disclosure;

FIG. 2 is an illustration of an example of a medical device for use with the system shown in FIG. 1 ;

FIG. 3 is an illustration of another example of a medical device for use with the system shown in FIG. 1 ;

FIG. 4 is an illustration of still another example of a medical device for use with the system shown in FIG. 1 ;

FIG. 5 is a side view of the medical device shown in FIG. 4 ;

FIG. 6 is an illustration of another example of a medical device for use with the system shown in FIG. 1 ;

FIG. 7 is an illustration of an example of a material construction of a portion of the medical device shown in FIG. 6 ; and

FIG. 8 is an illustration of an example of a handle assembly for a medical device.

DETAILED DESCRIPTION OF THE INVENTION

The present disclosure advantageously provides examples of medical systems and components thereof providing multiple effectively-controllable shapes or dimensions that can be selectively manipulated to provide varying treatment patterns. In particular and as shown in FIG. 1 , a medical system, generally designated as “10,” is provided for diagnosing and/or treating unwanted tissue conditions, including atrial fibrillation or other arrhythmias. The medical system may generally include a radiofrequency (“RF”) signal generator 12 having a user interface for the operation and control thereof, an electrocardiogram (“ECG”) unit 14 operably coupled to or otherwise interfaced with the RF signal generator 12, and a medical device 16 operably coupled to or otherwise interfaced with the RF signal generator 12 and/or the ECG unit 14.

Now referring to FIGS. 1-6 , the medical device 16 may include a catheter body sized and dimensioned to intraluminally and transseptally access a left atrium of a patient's heart for the subsequent treatment or ablation thereof. The medical device 16 may generally define an elongated, flexible catheter body 18 having a distal diagnostic/treatment assembly 20, as well as a handle assembly 22 at a proximal end or portion of the catheter body 18. The catheter body 18 may define one or more lumens therethrough, to allow for the passage of a guide wire 24 or the like therethrough. The catheter body 18 may include reinforcement elements or otherwise be constructed to provide desired degrees of stiffness, flexibility, and/or torque transmission along the length of the body and at discrete locations along the length thereof. For example, the catheter body 18 may include wires, braiding, increased wall-thickness, additional wall layering, sleeves, or other components reinforcing or otherwise supplementing an outer wall or thickness along its length. Discrete portions that may experience significant loading or torque during a particular procedure may also include such reinforcement.

Now referring to FIGS. 2-5 , the distal diagnostic/treatment assembly 20 provides for the treatment, monitoring, and/or otherwise clinically interacting with a desired tissue region, such as the heart. The treatment assembly 20 may include, for example, an electrode array 28 disposed near, on, or substantially on the distal end of the catheter body. The electrode array 28 may include a plurality of electrodes 30 along its length. These electrodes 30 may be symmetrically or asymmetrically mounted to detect electrical signals between any pair of electrodes (bi-pole) for mapping of electrical activity, and/or for performing other functions such as pacing of the heart. Moreover, the electrodes 30 may deliver ablation energy across an electrode pair or from independent electrodes when delivering monopolar energy. Each electrode 30 may include an integral thermocouple (not shown) located on or near the tissue side of the electrode to monitor the temperature at each ablation site before and during ablation. The electrodes 30 may be constructed from platinum, iridium, gold, silver or the like, and may measure approximately about 3 mm in length and separated by a distance of approximately 1 mm to approximately 4 mm, for example.

Each of the electrodes may be electrically coupled to the RF signal generator 12, which may also be attached to a patch or ground electrode 34 (attached to the back of the patient, for example) to enable the delivery of monopolar ablation energy when desired. While monopolar and bipolar RF ablation energy may be the selected forms of energy to pass through the electrodes of the medical device, other forms of ablation energy may be additionally or alternatively emitted from the treatment assembly, including electrical energy, magnetic energy, microwave energy, thermal energy (including heat and cryogenic energy) and combinations thereof. Moreover, other forms of energy that may be applied can include acoustic energy, sound energy, chemical energy, photonic energy, mechanical energy, physical energy, radiation energy and a combination thereof.

As shown in FIGS. 2-5 , the treatment assembly 20 of the medical device 16 may include a carrier assembly 36 that supports the electrode array 28 thereon. The carrier assembly 36 may include a flexible carrier arm 38 having one end coupled to the catheter body 18 and/or handle assembly 22. The carrier arm 38 may be constructed from a shape memory material, such as nitinol, to provide one or more pre-determined and/or biased geometric configurations. The carrier assembly 36 may include reinforcement elements or otherwise be constructed to provide desired degrees of stiffness, flexibility, and/or torque transmission along its length or at discrete locations along the length thereof. For example, the carrier arm 38 may include wires, braiding, increased wall-thickness, additional wall layering, sleeves, or other components reinforcing or otherwise supplementing an outer wall or thickness to minimize the likelihood of structural failure resulting from the experienced torque or strain. Conventional marking elements (e.g. radiopaque markers) may be included in the distal treatment assembly 20, carrier assemblies or other components of the medical device 16 to determine the relative location of the carrier assembly and/or the deployment condition of the carrier assembly, as well as confirm contact with tissue.

Referring now to FIGS. 2-3 , the carrier arm 38 may extend from a distal end of the catheter body 18 in a substantially coaxial arrangement with the catheter body 18 and/or a guide wire lumen defined therein. The carrier arm 38 may further define an opening or aperture 40 allowing passage of the guide wire 24 therethrough. As a result, the guide wire 24 may be used to direct the distal assembly 20 of the medical device 16 into a desired position within the patient when the carrier assembly 36 is in a minimized, substantially linear configuration. Further, the aperture 40 enables manipulation and steering of the guide wire 24 independently of the carrier assembly 36, allowing the distal portion of the medical device 16 to be directed over-the-wire irrespective of the geometric shape or configuration the carrier assembly is in, or what the particular rotational position of the carrier assembly is with respect to the guide wire 24. For example, FIG. 2 illustrates the carrier assembly 36 in a first geometric configuration for diagnosing or treating a tissue area, while FIG. 3 illustrates an additional geometric configuration.

Now turning to FIGS. 4-5 , the carrier assembly 36 may extend from a distal end of the catheter body 18 offset or spaced from an opening in the distal end where the guide wire 24 exits the catheter body 18. This configuration again allows for independent and separate operation or manipulation of the carrier assembly 36 and the guide wire 24 when the distal assembly 20 is in the treatment area, which may include for example one or more chambers of the heart.

The electrode array 28 may be arranged in a resiliently biased manner and have specific geometric configurations which generally allow the electrodes 30 to ablate specific tissue (such as a pulmonary vein, for example) having predetermined or otherwise known geometric or topographical characteristics. The electrode array 28 may be selectively movable from a primary, stored or delivery configuration for transport and delivery to the treatment site (such as a radially constrained configuration) to multiple secondary, deployed or expanded configurations for treatment. Referring now to FIGS. 2-5 , the electrodes 30 may be spaced along a fraction of the length of the carrier arm 38 (for example, between approximately 40% to approximately 60% of the overall length) such that, when deployed into an expanded configuration, the electrodes constitute a substantially semi-circular array. The fractional length and substantially semi-circular configuration of the electrodes allows a user to provide therapy with the electrodes around larger/common ostia or vessel orifices, as well as providing increased ability to create larger, wider-area patterns of treatment on more antral surfaces or tissue regions.

Referring now to FIGS. 6-7 , the medical device 16 may include a shaft 42 extending distally from the catheter body 18. The shaft 42 may be substantially rigid (e.g, constructed of stainless steel or the like) and define a lumen therein for the passage of the guide wire 24. A flexible coil 44 may be coupled to the shaft 42, and the coil 44 may be deflectable or steerable from the handle 22 of the device 16, and/or the coil 44 may define a lumen therethrough for passage of the guide wire 24 to facilitate over-the-wire direction of the medical device 16. An intermediate conduit 46 may be disposed between the shaft 42 and the coil 44, where the intermediate conduit provides a degree of rigidity less than the shaft 42 but greater than the coil 44, thus providing a transitional area that can deflect or bend to a degree during deflection or steering of the medical device 16. The intermediate conduit may be constructed, for example of nitinol or other material having the desired degree of flexibility.

The carrier arm 38 and/or carrier assembly 36 may be movably coupled to the shaft 42, and the shaft may be movable with respect the catheter body 18 to aid in shaping or manipulating the carrier assembly 36 into a desired configuration. The carrier arm 38 may define an eyelet or opening slidably positionable along a length of the shaft 42, for example. A distal stop 48 may be coupled to the shaft 42 to limit a range of movement of the carrier assembly 36 and/or prevent unintentional retraction/de-coupling of the shaft 42 and the carrier assembly 26. The stop 48 may include an expanded diameter portion or other mechanical obstacle preventing movement of the carrier assembly 36 past a certain point.

The handle assembly 22 of the medical device may include one or more mechanisms or components to facilitate manipulation of the shaft and/or the distal treatment assembly. For example, as shown in FIG. 8 , the handle assembly 22 may include a linear actuator 50 providing for the proximal-distal extension and retraction of the shaft 42 and/or carrier assembly 36. The linear actuator 50 may be movably coupled to a portion of the handle assembly 22 to allow it to slide or otherwise translate in a proximal-to-distal direction, and vice versa. The handle assembly 22 may further include a housing coupled to the linear actuator 50 and/or handle assembly 22 to facilitate movement and/or linkage of the actuator and the shaft 42 and/or carrier assembly 36.

A rotational actuator 52 may also be disposed on or about the handle assembly 22 to facilitate rotation of the shaft 42 and/or carrier assembly 36 about a longitudinal axis of the catheter body 18 in two directions. The rotational actuator 52 may be directly coupled to the shaft, or alternatively, include one or more intermediary components to effectuate a controllable, mechanical linkage between the rotational actuator and the shaft 42 and/or carrier assembly 36, such as a secondary gear assembly.

One or more internal push/pull wires may also be provided in the medical device 16, and in particular, coupled to the handle assembly 22. For example, to facilitate single or bi-directional steering and control of the distal treatment assembly 20, a full length pull wire (or double pull wires such as in the case with bi-directional steering, neither of which is shown) may be secured to the a distal portion of the end of the shaft 42 and/or carrier assembly 36. The pull wire may extend proximally to a steering knob 54. Rotation of the knob 54 may pull the wire that, in turn, controls the plane in which the electrodes contact tissue.

The medical device may further include a capture element 56 that is friction fit over a distal end of the handle assembly 22. The capture element 56 may be configured to be detached therefrom and slide in a distal direction over the catheter body 18 until the electrode array 28 is received therein, in a stored or confined configuration. The capture element 56 may be applied over the electrode array 28 for constraint and protection thereof during delivery through a hemostasis valve of a transseptal sheath or a vascular introducer. In this manner, the array may be introduced safely (e.g. without damage) into the patient's vasculature (e.g., a femoral vein). After introduction of electrode array 28 through the hemostasis valve, the capture element 56 may be moved proximally over the catheter body and reattached to the distal end portion of the handle assembly 22 to function as a strain relief.

The RF signal generator 12 functions to generate RF energy as supplied to selected catheter electrodes or between selected pairs of electrodes for the electrode array 28 to ablate or otherwise treat cardiac tissue. In particular, the RF signal generator 12 may be configured to generate and control the delivery of RF energy based on temperature feedback from the respective thermocouple of each electrode 30. Each electrode 30 may be independently monitored followed by temperature-controlled delivery of RF energy. Energy delivery may further automatically be duty-cycled to maximize the delivery of RF energy to the electrode based on the measured tissue temperature. Hence, as the tissue temperature increases due to delivery of RF energy (resistive heating), the electrodes 30 in turn increase in temperature, as monitored by the corresponding thermocouple. For instance, during bipolar delivery, if the set target temperature of the electrodes is 60° C. and one of the two electrodes is monitored at 55° C., while the other electrode is monitored to be at 50° C., the generator will selectively limit energy delivery based on the needs of one electrode measured at 55° C. This prevents either electrode of the pair from ever significantly surpassing the set target temperature. In contrast, during a monopolar phase of the energy delivery, the RF signal generator will deliver RF energy to each electrode 30 solely based on the temperature measured by its corresponding thermocouple. The temperature measurements may be performed between RF duty cycles (off-cycles) to minimize interference and to optimize accuracy of temperature readings.

The RF signal generator 12 may also include a user interface 56 and/or a remote control 58 (shown in FIG. 1 ). The user interface 56 allows a user to select parameters for the desired mapping and/or ablation treatment. The user interface 56 may allow the user to select an energy delivery mode for the treatment. For example, the user interface 56 can allow the user to select the delivery of only monopolar energy, only bipolar energy, or a combination of the two. The user interface may also allow the user to select a power ratio, such as 1:1, 2:1, or 4:1, when in combination mode. The generator 12 can be manufactured to include specific alternative power ratios (e.g., 1:1, 2:1, 4:1), such that the user can select one of the established ratios, and/or the user interface can allow the user to enter a different power ratio. The user interface 56 may also allow the user to change the energy mode when the catheter is changed, or when the medical device is moved to a different location in order to ablate different tissue.

The ECG unit 14 is provided to monitor and map signals detected by the electrodes of each electrode array. These two units (i.e., the RF signal generator 12 the ECG unit 14) may be interfaced in parallel, via the ECG interface 14, to the medical device 16. The ECG unit 14 electrically isolates the ECG unit 14 from any damaging signals generated by the RF generator 12. The ECG unit 14 may also be configured to isolate the ECG monitoring unit from electrical noise generated by the delivery of the RF energy.

In an exemplary use of the present system, the medical device 16 may be used to investigate and treat aberrant electrical impulses or signals in a selected tissue region, such as in the heart. Primarily, the distal treatment assembly 20 may be advanced through the patient's vasculature via the femoral vein over a previously inserted guide wire 24. The distal treatment assembly 20 may then be advanced into the right atrium and into proximity of a pulmonary vein, for example. In order to advance the carrier assembly 36 through the vasculature and into the desired position, the distal treatment assembly 20 (including the carrier assembly 36 and the electrode array 28) may be oriented in a first, substantially linear transport configuration. The first, substantially linear transport configuration may be achieved through the manipulation of the linear actuator 50 on the handle assembly 22. In turn, the flexible carrier arm 38 may be urged toward the substantially linear configuration. In this linear orientation, the carrier assembly is minimized and compact in a transverse dimension for easily advanced through the vasculature (or a transseptal sheath).

Once in the desired proximity to the target tissue, the carrier assembly 36 and the electrode array 28 may be deployed into a second, expanded geometric configuration using one or more of the rotational actuator 52 and/or linear actuator 50. Upon obtaining the desired geometric configuration of the carrier assembly and electrode array, the steering mechanism of the medical device (e.g., the steering knob 54 and the internal pull wire or wires) may be used to deflect the array 28 to contact the target tissue. The deflection may be achieved independently of the placement or manipulation of the guide wire 24. At this juncture, the geometric configuration of the electrode array 28 can be further adjusted to achieve optimal contact with the surrounding targeted tissue. Further, once a desired configuration of the carrier assembly 36 has been achieved, the configuration may be maintained when moving from one position or tissue treatment area to another region or tissue treatment area using the guide wire 24. Such methodology would allow a user, for example, to configure the carrier assembly 36 and electrode array 28 into the desired size or shape for a first pulmonary vein (or other tissue structure), then move the array 28 over the guide wire 24 to a similar structure (e.g., a second pulmonary vein) without the need to modify the shape of the array.

Once in the desired position, sufficient contact with tissue may be determined when the carrier assembly transitions to a convex shape or through fluoroscopic imaging. In addition, the location and tissue contact can be confirmed using the electrodes 30 of the medical device. For example, an electrophysiologist can map the contacted tissue to not only determine whether or not to ablate any tissue, but to also confirm tissue contact which is identified in the mapping procedure. If conditions are determined to be inadequate, an operator may adjust the shape or deflection of carrier assembly and/or the operator may reposition carrier assembly 36 against tissue through various manipulations performed at the proximal end of medical device 16. Moreover, it will be appreciated that other conventional mapping catheters can be applied to map signals, such as a standard electrophysiology lasso catheter.

Once sufficient tissue contact has been established and the mapping procedure has confirmed the presence of aberrant conductive pathways, ablation energy may be passed through the electrodes 30 (i.e., 5-10 Watts) of the electrode array 28. The electrode array 28 and the RF signal generator 12 may cooperate to deliver RF energy in monopolar, bipolar or combination monopolar-bipolar energy delivery modes, simultaneously or sequentially, and with or without durations of terminated energy delivery.

Depending upon a number of primary factors, such as the geometry and location of targeted tissue region, the quality of the electrode/tissue contact, the selected magnitude of the RF energy delivered to the electrodes, the type of RF energy applied, as well as the duration of the ablation, lesion formation can be estimated that is sufficient to eliminate aberrant conductive pathways therethrough. For example, given the above factors, a target temperature of the ablated tissue may be about 60° C., with a lower limit of about 55° C. and an upper limit of about 65° C.

It will be appreciated by persons skilled in the art that the present invention is not limited to what has been particularly shown and described herein above. In addition, unless mention was made above to the contrary, it should be noted that all of the accompanying drawings are not to scale. A variety of modifications and variations are possible in light of the above teachings without departing from the scope and spirit of the invention, which is limited only by the following claims. 

What is claimed is:
 1. A medical device, comprising: a handle assembly; an elongate catheter body coupled to the handle assembly and having a proximal portion, a distal portion, and a longitudinal axis, the elongate catheter body defining a guide wire lumen therethrough; a distal assembly defined by the distal portion of the elongate catheter body, the distal assembly including a flexible carrier arm coupled to the elongate catheter body, the carrier arm defining an aperture and having a plurality of electrodes and being transitionable between a substantially linear configuration and a substantially semi-circular configuration, all of the plurality of electrodes in the substantially semi-circular configuration being coplanar in a plane that is substantially orthogonal to the longitudinal axis of the elongate catheter body; a guide wire extending through the guide wire lumen and the aperture, and configured to direct the distal assembly into a desired position.
 2. The medical device of claim 1, wherein the handle assembly includes an actuator, and manipulation of the actuator of the handle assembly transitions the distal assembly into the substantially linear configuration by moving the flexible carrier arm into the substantially linear configuration.
 3. The medical device of claim 2, wherein the manipulation of the actuator of the handle assembly transitions the distal assembly into a substantially expanded configuration.
 4. The medical device of claim 3, wherein the handle assembly further comprises a steering mechanism with a steering knob and at least one internal pull wire.
 5. The medical device of claim 1, wherein the distal assembly further comprises at least one thermocouple, the thermocouple being configured to provide temperature feedback.
 6. The medical device of claim 5, further comprising an RF signal generator, the RF signal generator being configured to generate and control the delivery of RF energy based upon the temperature feedback from the at least one thermocouple.
 7. The medical device of claim 6, wherein the RF signal generator cooperates with the plurality of electrodes to deliver RF energy in at least one of the group consisting of monopolar, bipolar, or combination monopolar-bipolar energy delivery modes.
 8. The medical device of claim 7, wherein during bipolar energy delivery, a target temperature is set, and a first electrode and a second electrode is monitored to limit energy delivery to each electrode based upon the measurement of the temperature for each electrode relative to the target temperature.
 9. The medical device of claim 8 wherein during monopolar energy delivery the RF signal generator is configured to deliver RF energy to each electrode based upon a temperature measured by the at least one thermocouple.
 10. The medical device of claim 9, wherein the monopolar, bipolar, or combination monopolar-bipolar energy delivery modes are delivered simultaneously or sequentially.
 11. The medical device of claim 10, wherein the monopolar, bipolar, or combination monopolar-bipolar energy delivery modes are delivered with durations of terminated energy delivery or without durations of terminated energy delivery.
 12. The medical device of claim 1, wherein ablation energy is passed through the plurality of electrodes on the distal assembly at between 5-10 Watts. 